Are price discounts on sugar-sweetened beverages (SSB) linked to household SSB purchases? - a cross-sectional study in a large US household and retail scanner database.

BACKGROUND: Price promotions on sugar-sweetened beverages (SSBs) are commonly used by retailers to provide economic incentives for purchasing. Surprisingly, there is a lack of high-quality articles that examine the frequency and magnitude of sugary beverage discounting and consumer responses to discounts. The objective of this study is to quantify the association between exposure to price discounts and SSB purchases. METHODS: This cross-sectional study linked 2016 SSB consumption data from a U.S. household consumer panel (analytic sample N = 11,299 households) and weekly prices at stores where they shopped. We derived percent of the time SSBs were discounted (annual promotion frequency) and the amount of the discount (annual promotion magnitude) and assessed their association with household annual per capita SSB purchase ounces. Linear regression models adjusted for household size, income per capita, age, education, presence of children, race, occupation, region, and urbanicity. We also evaluated whether the association between promotion and purchase varied by socioeconomic status and race subgroups. Data were analyzed in 2019-2020. RESULTS: On average, households were exposed to SSBs price promotions 44% of the time. A 10-percentage point increase in annual SSB promotion frequency was associated with 13.7% increase in annual per capita purchasing (P < 0.0001), and a 1-percentage point increase in annual SSB promotion magnitude was associated with 15.3% increase in annual per capita purchasing (P < 0.0001). These associations did no vary significantly across socioeconomic status and race subgroups (Interaction P > 0.2). CONCLUSIONS: More frequent and deeper price promotion was associated with higher annual per capita SSB purchases. Restricting SSB price promotions may be effective at reducing SSB consumption.

Associations of Bar and Restaurant Smoking Bans With Smoking Behavior in the CARDIA Study: A 25-Year Study.

Indoor smoking bans have often been associated with reductions in smoking prevalence. However, few studies have evaluated their association with within-person changes in smoking behaviors. We linked longitudinal data from 5,105 adults aged 18-30 years at baseline from the Coronary Artery Risk Development in Young Adults (CARDIA) Study (1985-2011) to state, county, and local policies mandating 100% smoke-free bars and restaurants by census tract. We used fixed-effects models to examine the association of smoking bans with within-person change in current smoking risk, smoking intensity (smoking ≥10 cigarettes/day on average vs. <10 cigarettes/day), and quitting attempts, using both linear and nonlinear adjustment for secular trends. In models assuming a linear secular trend, smoking bans were associated with a decline in current smoking risk and smoking intensity and an increased likelihood of a quitting attempt. The association with current smoking was greatest among participants with a bachelor's degree or higher. In models with a nonlinear secular trend, pooled results were attenuated (confidence intervals included the null), but effect modification results were largely unchanged. Findings suggest that smoking ban associations may be difficult to disentangle from other tobacco control interventions and emphasize the importance of evaluating equity throughout policy implementation.

Neighborhood price of healthier food relative to unhealthy food and its association with type 2 diabetes and insulin resistance: The multi-ethnic study of atherosclerosis.

This study examined the association between the price of healthier food relative to unhealthy food and type 2 diabetes prevalence, incidence and insulin resistance (IR). Data came from the Multi-Ethnic Study of Atherosclerosis exam 5 administered 2010-2012 (exam 4, five years prior, was used only for diabetes incidence) and supermarket food/beverage prices derived from Information Resources Inc. For each individual, average price of a selection of healthier foods, unhealthy foods and their ratio was computed for supermarkets within 3miles of the person's residential address. Diabetes status was confirmed at each exam and IR was assessed via the homeostasis model assessment index. Multivariable-adjusted logistic, modified Poisson and linear regression models were used to model diabetes prevalence, incidence and IR, respectively as a function of price and covariates; 2353 to 3408 participants were included in analyses (depending on the outcome). A higher ratio of healthy-to-unhealthy neighborhood food price was associated with greater IR (4.8% higher HOMA-IR score for each standard deviation higher price ratio [95% CI -0.2% to 10.1%]) after adjusting for region, age, gender, race/ethnicity, family history of diabetes, income/wealth index, education, smoking status, physical activity, and neighborhood socioeconomic status. No association with diabetes incidence (relative risk=1.11, 95% CI 0.85 to 1.44) or prevalence (odds ratio=0.95, 95% CI 0.81 to 1.11) was observed. Higher neighborhood prices of healthier food relative to unhealthy food were positively associated with IR, but not with either diabetes outcome. This study provides new insight into the relationship between food prices with IR and diabetes.

Longitudinal Associations of Local Cigarette Prices and Smoking Bans with Smoking Behavior in the Multi-Ethnic Study of Atherosclerosis.

BACKGROUND: Few studies have examined associations of geographically proximal cigarette prices with within-person changes in smoking outcomes or assessed interactions between cigarette prices and smoking bans. METHODS: We linked neighborhood cigarette prices (inflation-adjusted) at chain supermarkets and drug stores and bar/restaurant smoking ban policies to cohort participants (632 smokers from the Multi-Ethnic Study of Atherosclerosis, 2001-2012, baseline mean age 58 years) using geocoded retailer and participant addresses. We used fixed-effects models to investigate associations of within-person changes in price and ban exposures with within-person changes in five smoking outcomes: current smoking, heavy (≥10 cigarettes) smoking, cessation, relapse, and intensity (average number of cigarettes smoked per day, natural log transformed). We assessed intensity associations among all smokers, and heavy (≥10 cigarettes per day) and light (<10) baseline smokers. Finally, we tested interactions between cigarette price and bans. RESULTS: A $1 increase in price was associated with a 3% reduction in risk of current smoking (adjusted risk ratio [aRR]: 0.97; 95% confidence interval [CI] = 0.93, 1.0), a 7% reduction in risk of heavy smoking (aRR: 0.93; CI = 0.87, 0.99), a 20% increase in risk of smoking cessation (aRR: 1.2; CI = 0.99, 1.4), and a 35% reduction in the average number of cigarettes smoked per day by heavy baseline smokers (ratio of geometric means: 0.65; CI = 0.45, 0.93). We found no association between smoking bans and outcomes, and no evidence that price effects were modified by the presence of bans. CONCLUSIONS: Results underscore the importance of local prices, but not hospitality smoking bans, in influencing older adults' smoking behaviors.

Healthy and Unhealthy Food Prices across Neighborhoods and Their Association with Neighborhood Socioeconomic Status and Proportion Black/Hispanic.

This paper evaluates variation in food prices within and between neighborhoods to improve our understanding of access to healthy foods in urbanized areas and potential economic incentives and barriers to consuming a higher-quality diet. Prices of a selection of healthier foods (dairy, fruit juice, and frozen vegetables) and unhealthy foods (soda, sweets, and salty snacks) were obtained from 1953 supermarkets across the USA during 2009-2012 and were linked to census block group socio-demographics. Analyses evaluated associations between neighborhood SES and proportion Black/Hispanic and the prices of healthier and unhealthy foods, and the relative price of healthier foods compared with unhealthy foods (healthy-to-unhealthy price ratio). Linear hierarchical regression models were used to explore geospatial variation and adjust for confounders. Overall, the price of healthier foods was nearly twice as high as the price of unhealthy foods ($0.590 vs $0.298 per serving; healthy-to-unhealthy price ratio of 1.99). This trend was consistent across all neighborhood characteristics. After adjusting for covariates, no association was found between food prices (healthy, unhealthy, or the healthy-to-unhealthy ratio) and neighborhood SES. Similarly, there was no association between the proportion Black/Hispanic and healthier food price, a very small positive association with unhealthy price, and a modest negative association with the healthy-to-unhealthy ratio. No major differences were seen in food prices across levels of neighborhood SES and proportion Black/Hispanic; however, the price of healthier food was twice as expensive as unhealthy food per serving on average.

The effects of mandatory seatbelt laws on seatbelt use, motor vehicle fatalities, and crash-related injuries among youths.

We provide the first comprehensive assessment of the effects of mandatory seatbelt laws on self-reported seatbelt use, highway fatalities, and crash-related injuries among high school age youths using data from the Centers for Disease Control's (CDC) national, state, and local Youth Risk Behavior Surveys (YRBS) and the Fatality Analysis Reporting System (FARS) from 1991 to 2005, a period spanning over 20 changes in state seatbelt laws. Our quasi-experimental approaches isolate the independent effects of seatbelt laws net of demographic characteristics, area and year fixed effects, and smooth area-specific trends. Across all data sources, we find consistent evidence that state mandatory seatbelt laws - particularly those permitting primary enforcement - significantly increased seatbelt use among high school age youths by 45-80%, primarily at the extensive margin. Unlike previous research for adults, however, we find evidence against the selective recruitment hypothesis: seatbelt laws had consistently larger effects on those most likely to be involved in traffic accidents (drinkers, alcohol-involved drivers). We also find that mandatory seatbelt laws significantly reduced traffic fatalities and serious injuries resulting from fatal crashes by 8 and 9%, respectively. Our results suggest that if all states had primary enforcement seatbelt laws then regular youth seatbelt use would be nearly universal and youth fatalities would fall by about 120 per year.

Can financial incentives help people trying to establish new habits? Experimental evidence with new gym members.

Can financial incentives aid habit formation in people attempting to establish a positive health behavior? We provide evidence on this question from a randomized controlled trial of modest-sized incentives to attend the gym among new members of a fitness facility. Our experiment randomized 690 participants into a control group that received a $30 payment unconditionally or one of 3 incentive groups that received a payment for attending the gym at least 9 times over the first 6 weeks of membership. Two incentive treatment arms offered monetary payments of $30 and $60. The third incentive treatment, motivated by the endowment effect, offered a physical item worth $30. All three incentives had only small impacts on attendance during members' first 6 weeks and no effect on their post-incentive visit trajectories. We document substantial overconfidence among new members about their likely visits and discuss how overconfidence may undermine the effectiveness of incentive programs.

The limits of simple implementation intentions: Evidence from a field experiment on making plans to exercise.

Recent large-scale randomized experiments find that helping people form implementation intentions by asking when and where they plan to act increases one-time actions, such as vaccinations, preventative screenings and voting. We investigate the effect of a simple scalable planning intervention on a repeated behavior using a randomized design involving 877 subjects at a private gym. Subjects were randomized into i) a treatment group who selected the days and times they intended to attend the gym over the next two weeks or ii) a control group who instead recorded their days of exercise in the prior two weeks. In contrast to recent studies, we find that the planning intervention did not have a positive effect on behavior. We observe a tightly estimated null effect even though the majority of subjects believed that planning is helpful and despite clear evidence that they engaged with the planning process.

Neighborhood Prices of Healthier and Unhealthier Foods and Associations with Diet Quality: Evidence from the Multi-Ethnic Study of Atherosclerosis.

It is known that the price of food influences the purchasing and consumption decisions of individuals; however, little work has examined if the price of healthier food relative to unhealthier food in an individual's neighborhood is associated with overall dietary quality while using data from multiple regions in the United States. Cross-sectional person-level data came from The Multi-Ethnic Study of Atherosclerosis (exam 5, 2010-2012 n = 2765); a food frequency questionnaire assessed diet. Supermarket food/beverage prices came from Information Resources Inc. (n = 794 supermarkets). For each individual, the average price of select indicators of healthier foods (vegetables, fruits, dairy) and unhealthier foods (soda, sweets, salty snacks), as well as their ratio, was computed for supermarkets within three miles of the person's residential address. Logistic regression estimated odds ratios of a high-quality diet (top quintile of Healthy Eating Index 2010) associated with healthy-to-unhealthy price ratio, adjusted for individual and neighborhood characteristics. Sensitivity analyses used an instrumental variable (IV) approach. Healthier foods cost nearly twice as much as unhealthier foods per serving on average (mean healthy-to-unhealthy ratio = 1.97 [SD 0.14]). A larger healthy-to-unhealthy price ratio was associated with lower odds of a high-quality diet (OR = 0.76 per SD increase in the ratio, 95% CI = [0.64-0.9]). IV analyses largely confirmed these findings although-as expected with IV adjustment-confidence intervals were wide (OR = 0.82 [0.57-1.19]). Policies to address the large price differences between healthier and unhealthy foods may help improve diet quality in the United States.

Relationship between HIV risk perception and condom use: Evidence from a population-based survey in Mozambique.

CONTEXT: The relationship between individuals' perception of their risk for acquiring HIV and their use of condoms is poorly understood. Understanding this relationship is crucial to the development of effective strategies to fight HIV and AIDS. METHODS: Data from the Mozambique 2001 Adolescent and Young Adult Reproductive Health and Behavior Risk Survey are used to compare 15-24-year-olds' assessments of their HIV risk with assessments based on current and past sexual behavior. In bivariate and probit regression analyses, the relationship between correct risk assessment and the likelihood of condom use at last intercourse is examined. RESULTS: Twenty-seven percent of women and 80% of men who considered themselves to have no risk or a small risk of contracting HIV were actually at moderate or high risk. For both men and women, the prevalence of condom use at last sex was more than twice as high among those who assessed their risk correctly (30% and 16%, respectively) as among those who did not (14% and 6%). Multivariate analysis showed that correct assessment was positively associated with condom use; the association was driven by use among never-married individuals. Never-married males who assessed their risk correctly were 18% more likely than other males to report condom use; never-married females, 17% more likely than other females. CONCLUSIONS: Educational messages should aim at enabling individuals to correctly assess their own HIV risk and encouraging behavior change based on self-assessment of risk.

Cigarette tax avoidance and evasion.

Variation in state cigarette taxes provides incentives for tax avoidance through smuggling, legal border crossing to low tax jurisdictions, or Internet purchasing. When taxes rise, tax paid sales of cigarettes will decline both because consumption will decrease and because tax avoidance will increase. The key innovation of this paper is to compare cigarette sales data to cigarette consumption data from the Behavioral Risk Factor Surveillance System (BRFSS). I show that after subtracting percent changes in consumption, residual percent changes in sales are associated with state cigarette tax changes implying the existence of tax avoidance. I estimate that the tax avoidance response to tax changes is at least twice the consumption response and that tax avoidance accounted for up to 9.6% of sales between 1985 and 2001. Because of the increase in tax avoidance, tax paid sales data understate the level of smoking and overstate the drop in smoking. I also find that the level of legal border crossing was very low relative to other forms of tax avoidance. If states have strong preferences for smoking control, they must pair high cigarette taxes with effective policies to curb smuggling and other forms of tax avoidance or employ alternative policies such as counter-advertising and smoking restrictions.

The effect of cigarette taxes on smoking among men and women.

The literature contains numerous studies that estimate the effect of cigarette taxes on smoking across various population groups. Although the conclusions are split, most US studies find that men are more responsive to cigarette taxes than women. This paper shows that these results are due to the failure to control for state-specific gender gaps in smoking rates that are correlated with cigarette taxes. When gender-specific state fixed effects are included to control for these gaps, the results indicate that women are nearly twice as responsive to cigarette taxes as are men. Since the econometric specification controls for variation in the tax response by household income, it is unlikely to be responsible for the difference.